University of Central Florida s7

APPENDIX H

University of Central Florida College of Education Counselor Education Program Evaluation

Withdrawal of Consent for Future Research

All students enrolled in the University of Central Florida Counselor Education Master’s degree program are required to participate in the program evaluation. Your participation in the program evaluation is mandatory. However, your participation in future research using this data is voluntary. You have the right to withdraw from future research at any time without consequence. To do so, complete this Withdrawal of Consent for Future Research form and forward it to the Principal Evaluator or one of the Co-Evaluators listed below.

Principal Evaluator: Edward (Mike) H. Robinson, III, Ph.D. Coordinator, Counselor Education Department of Child, Family and Community Sciences University of Central Florida Office: ED 322 N Phone: 407-823-3819 Email: [email protected]

Co-Evaluator: W. Bryce Hagedorn, PhD, LMHC, NCC, MAC Assistant Professor Department of Child, Family and Community Sciences College of Education University of Central Florida Office: ED 322 C Phone: 407-823-2999 Email: [email protected]

Co-Evaluator: Glenn Lambie, Ph.D.; LPC; NCC; NCSC; CCMHC Assistant Professor Department of Child, Family and Community Sciences College of Education University of Central Florida Office: ED 322 G Phone: 407-823-4967 Email: [email protected]

If you believe you have been injured during participation in this program evaluation, you may file a claim with UCF Environmental Health & Safety, Risk and Insurance Office, P.O. Box 163500, Orlando, FL 32816-3500 (407) 823-6300. The University of Central Florida is an agency of the State of Florida for purposes of sovereign immunity and the university’s and the state’s liability for personal injury or property damage is extremely limited under Florida law. Accordingly, the university’s and the state’s ability to compensate you for any personal injury or property damage suffered during this research project is very limited.

Research at the University of Central Florida involving human participants is carried out under the oversight of the Institutional Review Board. The office is open from 8:00 am to 5:00 pm Monday through Friday except on UCF official holidays. While this program evaluation is not research involving human participants, the IRB can provide valuable information regarding your rights as a participant in this program evaluation. This information may be obtained from:

Institutional Review Board (IRB) University of Central Florida (UCF) 12201 Research Parkway, Suite 501 Orlando, FL 32826-3246 Telephone: (407) 823-2901 or (407) 882-2276

 I wish to withdraw my consent for data collected by the University of Central Florida Counselor Education Program for program evaluation purposes to be used in future research.

Participant:______Date:______Signature

Participant:______Print Name

Principal Investigator (UCF):______Date:______